Prospective Solutions

Prospective risk adjustment uses data, analytics and clinical insights to identify care opportunities before or during a patient encounter. These insights can help providers evaluate, document and address conditions while care is being delivered.

The goal is to support a more complete and accurate picture of a member’s health status. When relevant information is available within the provider’s workflow, it can support more complete documentation, accurate coding and appropriate follow-up.

Health plans can improve prospective risk adjustment by making clinical insights easier for providers to access, understand and act on. Strong programs typically combine reliable data, clear workflows, provider enablement and consistent expectations for documentation.

Consistency is important across provider networks. Standardized processes and integrated workflows can help reduce variation, improve participation and support more reliable program performance over time.

Health plans may face challenges related to data quality, provider workflow variability, administrative burden and program scale. Differences in workflows, systems and documentation practices can make it harder to achieve consistent results.

Plans also need to balance accuracy, compliance and provider experience. Programs are more effective when they reduce unnecessary friction and help providers focus on clinically appropriate care and documentation.

Suspect conditions are identified by analyzing data from sources such as claims, medical records, pharmacy data, lab data and other clinical information. Analytics can help prioritize members for outreach and surface potential conditions that warrant clinical review.

These insights are not diagnoses on their own. They are prompts for providers to evaluate during the encounter and determine whether the condition is present, clinically supported and documented to the appropriate level of specificity.

Prospective risk adjustment can help payers:

• Improve documentation accuracy
• Support earlier identification of chronic conditions
• Enhance member engagement
• Reduce retrospective chart review efforts
• Strengthen provider collaboration
• Promote more complete risk score capture
• Support better health outcomes

Prospective approaches bring risk and quality information closer to the point of care and into provider workflows, where providers can assess conditions, address open gaps and document next steps as part of the patient visit.

When supported by clear workflows and accessible information, this approach can help strengthen follow up, improve documentation completeness and support more comprehensive patient assessments.

Prospective approaches can support provider engagement by making clinical insights easier to access and act on within existing workflows. When providers can review relevant data during the patient visit without switching systems, it can reduce administrative friction and foster participation.

Effective engagement also requires clear documentation expectations, education, support resources and performance visibility. Together, these practices can help create a more consistent provider experience while supporting more complete assessments and appropriate follow-up.

Medicare Advantage (MA), Affordable Care Act (ACA) and Medicaid plans can help reduce risk adjustment gaps and variability by creating more consistent approaches across provider networks. This includes using reliable data, prioritizing members effectively and supporting providers with clear documentation expectations.

A standardized approach aims to improve documentation consistency, support broader provider participation and make performance easier to measure across lines of business.

Optum supports prospective risk adjustment with analytics, workflow integration and provider engagement strategies designed to help health plans operate more consistently at scale. These capabilities are informed by experience across risk adjustment, quality and provider collaboration.

By connecting clinical insights to care delivery, Optum helps health plans support documentation completeness, reduce administrative friction and improve prospective program performance while keeping the provider and member experience central.

Optum supports prospective risk adjustment assessments through its In-Office Assessment program and Integrated In-Home and In-Office Assessment program. The In-Office Assessment program uses actionable data, interactive technology and field team support to help providers identify, assess and document patient health conditions during the care encounter.

For health plans that need more flexibility, the Integrated In-Home and In-Office Assessment program offers in-home, in-office and virtual visit options tailored to member needs. A unified data set across settings can help support better care management, quality and accurate reimbursement.